ASPEN Self-Assessment: Nutrition Assessment

Question 1

(T/F)
Catabolism of endogenous substrate including fat stored in adipose tissue (lipolysis) is common in both forms of malnutrition.

Answer 1

TRUE.
Hypoglycemia and ketosis are characteristic of starvation.
Hypermetabolism and hyperglycemia are characteristic of stress-related malnutrition.

Question 2

Explain albumin.

Answer 2

A negative acute-phase protein.
Levels decrease in response to stress and hypoalbuminemia is more a reflection of the degrees of stress resulting from disease, injury, and inflammation than nutritional status.
Hypoalbuminemia has been associated with increased short-term mortality, length of hospital stay, and complications and correlates strongly with 30-day mortality.

Question 3

Explain hyperhomocysteinemia.

Answer 3

Has been linked to an increased risk for coronary atherosclerosis.
Studies have shown that folic acid, vitamin B6, and vitamin B12 supplementation can reduce plasma homocysteine concentrations.
It is not known whether hyperhomocysteinemia is a causative factor of atherosclerosis or simply a marker of vascular disease.

Question 4

What are the appropriate fluid requirements for each below?

• Healthy adults, aged 18-55
• Healthy adults, aged 55-75
• Healthy adults, older than 75
• Fluid restriction

Answer 4

• Healthy, aged 18-55: 35 ml/kg
• Healthy, aged 55-75: 30 ml/kg
• Healthy, older than 75: 25 ml/kg
• FR: Less than 25 ml/kg

Question 5

Which amino acid is a key fuel for the small intestine?

Answer 5

Glutamine
It is essential for small intestinal structure and function.
Could be useful to supplement glutamine to patients who are suffering trauma or receiving PN.

Question 6

What are two conditionally essential amino acids?

Answer 6

Glutamine & Arginine

• Other conditionally essential AAs are: Cysteine, glycine, proline, and tyrosine
• Conditionally essential AAs are synthesized from other AAs under normal conditions but require a dietary source in order to meet increased needs caused by metabolic stress.
  (a) Example: Arginine becomes conditionally essential for wound healing.

Question 7

Explain the recommendations for vitamin A deficiency with and without concurrent corticosteroid therapy.

Answer 7

For deficiency: 2,000 to 200,000 IU/day (606 - 60,600 RAE/day)

To counteract the inhibitory effects that steroids have on collagen synthesis and connective tissue repair: 3,000 to 15,000 RAE/day x 7 days orally

To enhance wound healing with concurrent corticosteroid use: 3,000 to 4,500 RAE/day orally

Question 8

Zinc deficiency is most commonly associated with?

Answer 8

Diarrhea
The overall biochemical functions of zinc can be categorized as catalytic, structural, and/or regulatory in nature. Additional zinc is recommended in patients with additional losses from thermal injury, excessive GI losses such as diarrhea, decubitus ulcers, and high output fistulas

Question 9

Copper toxicity is associated with what disease?

Answer 9

Liver Disease

• Copper toxicity can cause severe N/D/V. More serious manifestations with acute or more chronic toxic ingestion or Wilson’s disease include: coma, hepatic necrosis, liver failure, renal failure, vascular collapse, and death.
• Since about 80% of copper is excreted in the bile, patients who have liver disease should be monitored and supplementation reduced or eliminated.
• HD increases copper losses
• Enteral zinc supplementation can complete with copper for absorption.

Question 10

What can result in an invalid IC measurement?

Answer 10

Chest tube leak

• IC is a respiratory measurement that under proper conditions is equivalent to metabolism, any factor that violates these conditions is a contraindication to IC.
• Examples: air leaks; extracorporeal membrane oxygenation(ECMO); HD; FiO2 > 60 in mech. vented patients; and for spontaneously breathing patients - reliance on supplemental oxygen; inability to cooperate with measurement, and claustrophobia or anxiety

-If RMR is the desired value to be measured (it usually is), then any factor that prevents that patient from being at rest or cooperating with the device operator is also a contraindication.

Question 11

Explain REE.

Answer 11

Resting Energy Expenditure

• REE measured under steady stable conditions closely approximates true 24-hour energy expenditure.
• The addition of a stress or activity factor may not be necessary and could result in overfeeding.
• If a patient is measured while fasting or if feedings are intermittently provided, it is reasonable to allow an additional 5% factor to account for thermogenesis.
• Therefore, a critically ill patient’s energy delivery in response to REE does not need to be modified when measured by IC. AKA No stress/activity factors are needed.

Question 12

Explain respiratory quotient (RQ).

Answer 12

RQ = CO2 produced/O2 consumed

Defined as the volume of CO2 released over the volume of O2 absorbed during respiration.

Question 13

RQ <0.7 or >1.0 means?

Answer 13

Hypoventilation or hyperventilation

Question 14

RQ of 0.71 means?

Answer 14

Primarily fat oxidation

Question 15

RQ of 0.82 means?

Answer 15

Primarily protein oxidation

Question 16

RQ of 0.85 means?

Answer 16

Suggests mixed substrate utilization

Question 17

RQ of 1.0 means?

Answer 17

Carbohydrate oxidation

Question 18

Facts about Crohn’s disease.

Answer 18

Malnutrition is the most common in this form of inflammatory bowel disease because Crohn’s usually involves the small intestine

• Can impact any area of the GI tract (mouth to anus)
• Depending on severity of illness, weight loss has been reported in 20% to 85% of those with Crohn’s
• 65-75% of inpatients and more than 50% of outpatients experience significant weight loss
• Possible mechanism for malnutrition in this disease: Malabsorption from diseased small bowel mucosa; increased nutrient requirements from active inflammation; and reduced oral food intake due to abdominal discomfort and diarrhea

Question 19

Explain appropriate treatment for ascites.

• Fluid
• Sodium
• Protein

Answer 19

Includes fluids and sodium restriction.

• Protein intake: 1.0 - 1.5 g/kg/day for patients with cirrhosis.
• While optimum nutrition support may not be possible, use of maximally concentrated solutions provides the best opportunity to avoid further salt and fluid overload while providing necessary substrate for anabolism

Question 20

Where is dietary fat primarily absorbed?

Answer 20

Duodenum and proximal jejunum

• Dietary fat is absorbed in the proximal small bowel
• Lingual lipase released in the mouth and gastric lipase produced in the stomach have a limited role in fat digestion in healthy adults.
• Bile acids secreted by the liver as well as lipase and colipase produced by the pancreas aid in the micellar solubilization and absorption of dietary fat.

Question 21

Resections and nutrient absorption.

Answer 21

Resections of the proximal bowel, including the duodenum and proximal jejunum, are generally better tolerated because of ileal compensation and adaption.

• In general, ileal resection is poorly tolerated because of adaptive hyperplasia in the remaining jejunum is limited.
• The ileocecal valve slows intestinal transit allowing for greater absorption of nutrients.
• Colon has critical roles in fluid and nutrient absorption.
• Therefore, patients lacking a colon are at greater risk of dehydration.
• The colon is capable of salvaging calories through anaerobic bacterial fermentation of undigested carbohydrates into SCFAs.

Question 22

Explain methotrexate.

Answer 22

Methotrexate acts by interfering with the normal intracellular metabolism of FOLATE.

• Drug used to treat cancer
• It is a folate analogue that became available in the 1950s
• Structurally similar to FOLATE
• It competitively inhibits dihydrofolate reductase (an enzyme that catalyses the conversion of dihydrofolate to tetrahydrofolate, a cofactor in the synthesis of purine nucleotides and thymidylate.
• Therefore, methotrexate impairs malignant growth by interfering with the DNA synthesis, repair and cellular replication.

Question 23

Copper deficiency is associated with?

Answer 23

Microcytic hypochromic anemia

• Patients on long-term PN have developed anemia, leukopenia, neutropenia, and skeletal abnormalities.
• Other symptoms of copper deficiency are: sensory ataxia, lower extremity spasticity, parathesis in extremities, leukopenia, neutropenia, and hypercholesterolemia

Question 24

Deficiencies of B12 or folate result in what?

Answer 24

Macrocytic anemia (large red blood cells)

Question 25

Does a prominent iliac crest pertain to muscle or fat loss?

Answer 25

SubQ fat loss

Question 26

Explain SGA

Answer 26

Subjective Global Assessment (SGA)

• Uses 5 historical components (weight history, dietary intakes, GI symptoms, functional status, and metabolic demand)
• 3 physical components (Fat depletion, muscle wasting, and nutrition-related edema)

Question 27

(TRUE/FALSE) SGA is appropriate for use in critically ill patients?

Answer 27

FALSE

ASPEN and SCCM recommend the use of NRS-2002 or NUTRIC tool to determine risk in this patient population.

Question 28

Explain NRS-2002 tool.

Answer 28

Appropriate for critically ill patients (5 Factors):

1. Unintentional weight loss
2. BMI
3. Disease severity
4. Impaired general condition
5. Age >70

Question 29

Explain the NUTRIC tool.

Answer 29

Appropriate for critically ill patients (5 Factors)
“Nutrition Risk in Critically Ill”
**Focuses on the severity of illness

1. Age
2. APACHE II score (ICU mortality prediction score)
3. SOFA (Sequential Organ Failure Assessment)
4. # of comorbidities
5. Days from hospital to ICU admission

Question 30

Explain NRI tool.

Answer 30

“Nutritional Risk Index (NRI)”

Uses serum albumin and the ratio of current weight to the usual weight

Question 31

What does an elevated C-reactive protein indicate?

Answer 31

Inflammatory status, which may be the reason for hypoalbuminemia.
-Positive acute-phase proteins such as CRP increase during inflammation, whereas negative acute-phase proteins concentrations such as albumin and pre-albumin decrease during inflammation.

Question 32

Where is iron primarily absorbed?

Answer 32

Jejunum

Question 33

Cheilosis is a physical symptom associated with a deficiency of?

Answer 33

Riboflavin

-Cheilosis = cracking of the corners of the mouth